IMCI Health Facility Survey - World Health Organization · IMCI Health Facility Survey World Health...

64
Sudan March - April 2003 IMCI Health Facility Survey World Health Organization Regional Office for the Eastern Mediterranean Federal Ministry of Health Republic of Sudan

Transcript of IMCI Health Facility Survey - World Health Organization · IMCI Health Facility Survey World Health...

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SudanMarch - April 2003

IMCI Health Facility Survey

World Health OrganizationRegional Office for theEastern Mediterranean

Federal Ministry of HealthRepublic of Sudan

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OBJECTIVES

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! To assess the quality of outpatient care, including both clinical and counselling care, provided to sick children aged 2 months up to 5 years old at health facilities implementing the IMCI strategy;

To describe organizational and other “healthsystems support” elements influencing the quality of care and identify major constraintsto it;

! To measure key indicators of quality care to monitor progress of the IMCI strategy at health facilities; and

! To recommend further approaches to improving the quality of outpatient child health services.

!

2

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METHODOLOGY

3

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SELECTION OF HEALTH FACILITIES

Systematic, random selection of 66 health facilities from a list of 136 facilities in8 States in urban and rural areas and bytype of facility:

! implementing IMCI; and

! with estimated daily caseload ofat least 2 cases below 5 years old

4

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DISTRIBUTION OF HEALTH FACILITIES IN THE SAMPLEBY LOCATION AND TYPE

2

32

6

3

1112

Hospitals

No

. o

f fa

cilit

ies

Health centres Dispensaries

0

5

10

15

20

25

30

35Urban

Rural

5

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SURVEY FINDINGS

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1. Sample characteristics

2. Quality of clinical care

3. Factors influencing care

7

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1. SAMPLE CHARACTERISTICS

! Case management observations:364 children aged 2 months up to5 years old

! Gender of cases: 46.7% female

! Age: 54.3% under 2 years old

! Caretakers interviewed: 350

! Mother caretakers: 82.6%

8

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CASES MANAGED BY TYPE OF HEALTH PROVIDER (N = 364)

Nurses3%

Medical Assistants77%

Doctors20%

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2. QUALITY OF CLINICAL CARE

! ASSESSMENT

! Classification

! Treatment and advice

! ASSESSMENT

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DISTRIBUTION OF MAIN CONDITIONS IDENTIFIED IN THE SAMPLE (N = 364)

Acute respiratoryinfections

Fever

Diarrhoeal diseases

Anaemia

Eye infections

Ear problem

Severe malnutritionand Very low weight

Needing urgent referral

Percentage of all cases0 20 40 60 80 100

63

57

30

17

11

9

7

4

11

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INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX

5.9 out of 10 tasks

Child weight taken and checkedagainst growth chart

Child checked for 3 main symptoms(cough, diarrhoea and fever)

Child checked for 3 generaldanger signs

Child road-to-health card asked for

Child checked for palmar pallor

WHO Index of integratedassessment

75%

60%

53%

45%

21%

9%

Child vaccination status checked

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INTEGRATED ASSESSMENT (1): MAIN TASKS AND INDEXTRAINED vs UNTRAINED

Child vaccination status checked

Child weight taken and checkedagainst growth chart

Child checked for 3 main symptoms(cough, diarrhoea and fever)

Child checked for 3 generaldanger signs

Child road-to-health card asked for

Child checked for palmar pallor

WHO Index of integratedassessment

79%

71%

63%

58%

28%

10%

6.6

62%

23%

19%

0%

0%

5%

3.4

Trained

Untrained

outof 10tasks

13

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PERFORMANCE OF SELECTED TASKS:TAKING TEMPERATURE AND WEIGHT

48

14

82

53

Temperaturetaken

Temperaturetaken correctly

Weighttaken

Weight takencorrectly

Perc

en

tag

e o

f ca

ses

in w

hic

h t

ask

do

ne

0

10

20

30

40

50

60

70

80

90

100

Temperature Weight14

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PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHTTRAINED vs UNTRAINED

4 0

55

46

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

ses

in w

ho

m t

ask

do

ne

61

18

91

55

Temperaturetaken

Temperaturetaken correctly

Weighttaken

Weight takencorrectly

Trained

Untrained

Temperature Weight15

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PERFORMANCE OF SELECTED ASSESSMENT TASKS: ARI (N = 228) AND DIARRHOEA (N = 109)

76

57

76

57

51

69

33

0

10

20

30

40

50

60

70

80

90

100 Acute respiratory infections (ARI)

Diarrhoea

Respiratoryrate

counted

Respiratoryrate

countedcorrectly

Duration of diarrhoeaepisode

asked about

Presenceof blood instool asked

about

Somethingto drinkoffered

Abdomenskin

pinched

Abdomenskin

pinchedcorrectly

Perc

en

tag

e o

f ca

ses

in w

ho

m t

ask

do

ne

ARI Diarrhoea16

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SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEATRAINED vs UNTRAINED

0

10

20

30

40

50

60

70

80

90

100

Respiratoryrate

counted

Respiratoryrate

countedcorrectly

Duration of diarrhoeaepisode

asked about

Presenceof blood instool asked

about

Somethingto drinkoffered

Abdomenskin

pinched

Abdomenskin

pinchedcorrectly

89

77

88

6964

82

41

15

33 33

13

4

21

4

Perc

en

tag

e o

f ca

ses

in w

ho

m t

ask

do

ne

Trained

Untrained

ARI Diarrhoea17

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ASSESSMENT OF FEEDING PRACTICES:CHILDREN LESS THAN 2 YEARS OLD (N = 189) AND OLDER CHILDREN

WITH VERY LOW WEIGHT AND/OR ANAEMIA (N = 36)

Assessed for feedingpractices

Not assessed

76%

24%18

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ASSESSMENT OF FEEDING PRACTICES IN THE TARGET GROUPTRAINED UNTRAINEDvs

Child 2 years old or older with verylow weight and/oranaemia assessed

35

7

30

0 0 0

Child under2 years oldassessed

Both groupsassessed for

feeding practices

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

Perc

en

tag

e o

f ca

ses

in w

ho

m t

ask

do

ne

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2. QUALITY OF CLINICAL CARE

! Assessment

! CLASSIFICATION

! Treatment and advice

! CLASSIFICATION

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AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS

72

56

50

38

37

36

33

25

21

46

Very severe febrile disease ormalaria N=65

Very severe disease/severepneumonia or pneumonia

Dysentery N=8

Severe malnutrition or verylow weight N=26

Mastoiditis or acute or chronicear infection N=27

Diarrhoea with severe or somedehydration N=11

Severe or non-severe persistentdiarrhoea N=10

Complicated or uncomplicatedmeasles N=4

Severe anaemia or anaemiaN=61

TOTAL AGREEMENT ONALL CLASSIFICATIONS ABOVE

Percentage of matching classifications

0 20 40 60 80 100

21

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AGREEMENT ON CLASSIFICATIONSTRAINED UNTRAINEDvs

Very severe febrile diseaseor malaria

Very severe disease/severepneumonia or pneumonia

Dysentery

Severe malnutrition orvery low weight

Mastoiditis or acute orchronic ear infection

Diarrhoea with severe orsome dehydration

Severe or non-severepersistent diarrhoea

Complicated oruncomplicated measles

Severe anaemia or anaemia

AGREEMENT ON OVERALLCHILD CLASSIFICATIONS

Percentage of matching classifications

71

59

50

43

30

50

43

0

23

0

49

77

40

20

75

0

0

14

0

49

Danger signs

Trained

Untrained

No cases seen

No cases seen

0 20 40 60 80 100

22

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2. QUALITY OF CLINICAL CARE

! Assessment

! Classification

! TREATMENT AND ADVICE

23

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MANAGEMENT OF SEVERE CASES NEEDING URGENT REFERRAL (N = 14):SEVERE CASES IDENTIFIED AND REFERRED

Severe cases identifiedand referred

43%

Severe cases missedand/or

57%not referred

All the 6 children correctlyreferred out of the 14 severe

cases were identifiedby IMCI-trained providers

24

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PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT(N = 80 CASES WITH "IMCI CONDITIONS" NEEDING ORAL ANTIBIOTICS)

7368

33

Prescribedoral antibiotics

Prescribedrecommendedoral antibiotics

Prescribedantibioticscorrectly

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

ses

with

an

IM

CI co

nd

itio

nn

eed

ing

an

tib

iotics

25

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PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT FORIMCI CONDITIONS (1)

TRAINED UNTRAINEDvs

71 70

38

82

55

00

10

20

30

40

50

60

70

80

90

100

Prescribedoral antibiotics

Prescribedrecommendedoral antibiotics

Prescribedantibioticscorrectly

Trained

Untrained

Perc

en

tag

e o

f ca

ses

with

an

IM

CI co

nd

itio

nn

eed

ing

an

tib

iotics

26

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PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTICS FORIMCI CONDITIONS (2)

TRAINED UNTRAINEDvs

0

10

20

30

40

50

60

70

80

90

100

63

92

73

54

17

67

17

0

Correct dose Correctfrequency

Correctduration

CORRECTPRESCRIPTION

Trained

Untrained

Perc

en

tag

e o

f ca

ses

giv

en

a r

eco

mm

en

ded

an

tib

iotic

27

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CARETAKER CORRECT KNOWLEDGE ABOUT ORAL ANTIBIOTIC TREATMENT (IMCI CONDITIONS)

TRAINED UNTRAINEDvs

49

59

45

25

0

11

22

CORRECTKNOWLEDGE

0

10

20

30

40

50

60

70

80

90

100

0

Correct dose Correctfrequency

Correctduration

Trained

Untrained

Perc

en

tag

e o

f ca

reta

kers

of

case

s g

iven

are

com

men

ded

an

tib

iotic

28

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CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ONDURATION OF ORAL ANTIBIOTIC TREATMENT

SHOULD CHILD GET BETTER BEFORE COMPLETING TREATMENT COURSE

Other / don't know12%

Would continue but reduce dose1%Would stop treatment

22%

Would continue as advised65%

29

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RATIONAL USE OF DRUGS:CASES NOT NEEDING ANTIBIOTICS GIVEN NO ANTIBIOTICS (N = 254)

Cases correctly prescribedno antibiotics

63%

Cases prescribed antibioticsbut not needing them

37% 30

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74

26

26

74

0

20

40

60

80

100

Pe

rce

nta

ge

of ca

se

s n

ot n

ee

din

g a

ntib

iotic

s

Given no antibiotics Given antibiotics but not needing them

RATIONAL USE OF ANTIBIOTICSTRAINED UNTRAINEDvs

Trained Untrained31

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PRESCRIPTION OF RECOMMENDED ORAL ANTIMALARIAL TREATMENT(N = 62)

74 74

27

Perc

en

tag

e o

f ca

ses

with

mala

ria

Prescribed oralantimalarials

Prescribedrecommended

oral antimalarials

Prescribed antimalarialscorrectly

0

10

20

30

40

50

60

70

80

90

100

32

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76 76

41

69 69

22

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

PRESCRIPTION OF ORAL ANTIMALARIAL TREATMENTTRAINED UNTRAINEDvs

Prescribed oralantimalarials

Prescribedrecommended

oral antimalarials

Prescribed antimalarialscorrectly

Perc

en

tag

e o

f ca

ses

with

mala

ria

33

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43

78 76

41

56

100

56

22

Correct dose Correct frequency Correct duration CORRECTPRESCRIPTION

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

Perc

en

tag

e o

f ca

ses

giv

en

an

tim

ala

rials

PRESCRIPTION OF ORAL ANTIMALARIALSTRAINED UNTRAINEDvs

34

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Correct dose Correct frequency Correct duration CORRECTKNOWLEDGE

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

CARETAKER CORRECT KNOWLEDGE ABOUT ANTIMALARIAL TREATMENTTRAINED UNTRAINEDvs

3538

43

24

0

22

0 0

Perc

en

tag

e o

f ca

ses

giv

en

an

tim

ala

rials

35

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ADVICE ON ORSTRAINED UNTRAINEDvs

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

Perc

en

tag

e o

f ca

ses

giv

en

ORS

72

4440 40

0 0 0 0

Correct amountof water to

prepare ORS

Correct adviceon when

to give ORS

Correct advice onhow much ORS to

give each time

CORRECTADVICEON ORS

36

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CARETAKER KNOWLEDGE ABOUT ORS PREPARATIONAND ADMINISTRATION

TRAINED UNTRAINEDvs

79

35

56

28

73

9

27

9

Knows correctamount of waterto prepare ORS

Knowswhen togive ORS

Knows howmuch ORS to

give each time

CORRECTKNOWLEDGEABOUT ORS

0

10

20

30

40

50

60

70

80

90

100 Trained

Untrained

Perc

en

tag

e o

f ca

ses

giv

en

ORS

37

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24 26

17

49

Cases with eyeinfection given

tetracyclineointment (N =41)

Cases needingVitamin A given

Vitamin A(N =46)

Cases needingvaccine given

it or toldwhen/where

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f elig

ible

ch

ildre

n

Cases withanaemia

prescribediron (N = 55)

OTHER CURATIVE AND PREVENTIVE TREATMENTS AND OPPORTUNITIESFOR IMMUNIZATION FOR NON-REFERRED CASES

38

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CASES GIVEN ADVICE ON HOME CARE BY PROVIDER ANDCARETAKER KNOWLEDGE

Signs to takechild back

immediately

ALL THREEHOME CARE

RULES

Continue feedingGive extra fluids

4138

20

12

48

79

62

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e

Advised by provider

Known by caretaker

39

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ADVICE ON HOME CARE GIVEN BY PROVIDERTRAINED UNTRAINEDvs

5249

26

15

51 0 0

Advised to giveextra fluids

Advised tocontinue feeding

Advised on signsto take child

back immediately

ADVISED ONALL THREE HOME

CARE RULES

Trained

Untrained

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

ses

40

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CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELYAND KNOWING ABOUT THEM

32

21

25

21

19

14

5

32

5

70

18

4

2

1

SIGNS FOR ALL:Becomes sicker

Unable to drink

FOR NO FEVER:Develops a fever

FOR NO PNEUMONIA:Develops difficult breathing

Develops fastbreathing

FOR NO DEHYDRATION:Has blood in stools

Drinks poorly

0 20 40 60 80 100

Percentage of cases

Caretaker advised

Caretaker knowing

41

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CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ONFREQUENCY OF FEEDING

Given no or incorrect advice76%

Given correct advice24%

42

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52

21 20

10

Has a mosquitobednet

Has a treatedmosquito bednet

Child sleptunder bednetprevious night

CHILD SLEPTUNDER TREATED

BEDNET PREVIOUSNIGHT

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

reta

kers

in

terv

iew

ed

MOSQUITO BEDNETS AND THEIR USE (N = 350)

43

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USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES

34

5

26 25 23

Home carecard used(N = 347)

Home carecard and

communicationtechniques

used (N = 347)

Card heldproperly

Picturespointed at

Caretakerunderstanding

checked

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

ses

Details on communication techniques(N = 118 cases in whom card used)

44

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USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUESTRAINED UNTRAINEDvs

Home carecard used

Home carecard and

communicationtechniques

used

Card heldproperly

Picturespointed at

Caretakerunderstanding

checked

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f ca

ses

Details on communication techniques(cases in whom home care card used)

44

7

26 25 23

0 0 0 00

45

Trained

Untrained

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3. FACTORS INFLUENCING CARE

! Drug availability

! Availability of supply for IMCI

! Availability of supply for immunization

! Availability of supply for malaria laboratory

! Availability of other supply

! Supervision

46

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6

12

4

5

8.7

2.6

Essential oraltreatments

Non-injectabledrugs

Pre-referralinjectable drugs

0

2

4

6

8

10

12

14

Ind

ex

Index if all key drugs availablein all facilities

Mean no. of key drugs availablein the facilities surveyed

INDEX (MEAN) OF DRUG AVAILABILITY (N = 66 FACILITIES)(Availability of at least 1 treatment course)

47

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94

91

89

88

79

45

15

Working baby scale

Source of clean water

Working timing device

Supplies to mix ORS

Thermometer

Working adult scale

Working nebulizer

0 20 40 60 80 100

Percentage of the 66 facilities in which item available

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI

48

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92

77

32

17

36

1. Needlesand syringes

Safety boxto dispose

of usedneedles and

syringes

2a. Functioningrefrigeratorwith correcttemperature

2b. Coldbox and

all icepacksfrozen

AVAILABILITY OFSUPPLY AND

EQUIPMENT FORIMMUNIZATION

(1 AND 2)

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f th

e 5

3 f

aci

litie

s in

wh

ich

ite

m a

vaila

ble

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATIONAT 53 FACILITIES PROVIDING IMMUNIZATION SERVICES

49

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AVAILABILITY OF KEY SUPPLY AND EQUIPMENT FOR MALARIALABORATORY

77

77

70

68

62

Giemsa

Slides

Functioning microscope

Lancets to prick finger

ALL 4 ITEMS FORMALARIA LABORATORY

0 20 40 60 80 100

Percentage of the 66 facilities with the items available50

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AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS,CHART BOOKLET AND OTHER RECORDS

88

77

77

70

65

65

41

IMCI chart booklet

Mother home carecounselling card for

provider use

IMCI recording forms

Road-to-health cards

IMCI daily register

Vaccination register

Drug stock cards

0 20 40 60 80 100

Percentage of the 66 facilities in which item available51

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SUPERVISION IN THE 66 FACILITIES VISITED

50

11

26

15

2

Received atleast 1 supervisory

visit in the past6 months

Casemanagementobserved in

past 6 months

Hassupervisory

book

Last visit'srecommendations

recordedon the book

Clinicalsupervisiondone and

findings recorded

0

10

20

30

40

50

60

70

80

90

100

Perc

en

tag

e o

f all

66

faci

litie

s

52

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CONCLUSIONS

535555

CONCLUSIONS

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54

1. Better clinical performance of staff trained in IMCIthan those untrained

IMCI training can improve quality ofoutpatient child care

2. Very low clinical performance of staff not trainedin IMCI

Issue of pre-service training standards

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3. Weak health systems support elements

Major constraint to delivery ofquality child care services and

IMCI implementation

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RECOMMENDATIONS

TO FURTHER IMPROVE

OUTPATIENT CHILD

HEALTH SERVICES

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POLICY: EQUITABLE ACCESS TODRUGS AND SERVICES

Consideration should be given to protecting

children below 2 years old, especially in poor

families, by issuing a policy and establishing

mechanisms to provide affordable drugs to them

States should commit to making key drugs

regularly available to the health facilities where

IMCI-trained staff work, to make the most of the

substantial investment placed in IMCI training

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TRAINING: BASIC SKILLS AND SKILLREINFORCEMENT

Consideration should be given to strengthening

pre-service training curriculum of medical

assistants and introducing the IMCI outpatient

care approach as a way to develop basic skills

The Federal level and States concerned should

jointly plan to develop and commit adequate

human resources to follow up visits after IMCI

training, to conduct them on a timely basis and

according to standard methodology

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SUPERVISION: MALARIA LABORATORYAND ROUTINE SUPERVISION

Close supervision by Federal and State levels with

quality control of malaria microscopic diagnosis

should be carried out regularly to improve the

quality of malaria laboratory diagnosis

A training package on supervision of child health

services should be developed. Supervisors

responsible for routine supervision should be

trained in child health supervisory skills and

involved in IMCI follow-up visits

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The Italian Cooperation